Burnout among primary health-care professionals in low- and middle-income countries: systematic review and meta-analysis

Abstract Objective To estimate the prevalence of burnout among primary health-care professionals in low- and middle-income countries and to identify factors associated with burnout. Methods We systematically searched nine databases up to February 2022 to identify studies investigating burnout in primary health-care professionals in low- and middle-income countries. There were no language limitations and we included observational studies. Two independent reviewers completed screening, study selection, data extraction and quality appraisal. Random-effects meta-analysis was used to estimate overall burnout prevalence as assessed using the Maslach Burnout Inventory subscales of emotional exhaustion, depersonalization and personal accomplishment. We narratively report factors associated with burnout. Findings The search returned 1568 articles. After selection, 60 studies from 20 countries were included in the narrative review and 31 were included in the meta-analysis. Three studies collected data during the coronavirus disease 2019 pandemic but provided limited evidence on the impact of the disease on burnout. The overall single-point prevalence of burnout ranged from 2.5% to 87.9% (43 studies). In the meta-analysis (31 studies), the pooled prevalence of a high level of emotional exhaustion was 28.1% (95% confidence interval, CI: 21.5–33.5), a high level of depersonalization was 16.4% (95% CI: 10.1–22.9) and a high level of reduced personal accomplishment was 31.9% (95% CI: 21.7–39.1). Conclusion The substantial prevalence of burnout among primary health-care professionals in low- and middle-income countries has implications for patient safety, care quality and workforce planning. Further cross-sectional studies are needed to help identify evidence-based solutions, particularly in Africa and South-East Asia.


Introduction
Burnout is defined as a form of chronic occupational stress consisting of three dimensions: (i) exhaustion; (ii) depersonalization or cynicism; and (iii) feelings of inefficacy. 1 Although the burden of burnout in high-income countries is well established, less is known about low-and middle-income countries. Knowledge about burnout is important because of its substantial consequences. [2][3][4][5][6] Among health-care professionals, burnout has been associated with patient safety concerns and poor quality of care. 2 There is also an impact on physical and mental health and an increase in sick leave, staff turnover and emigration rates. [3][4][5][6][7] Moreover, burnout can increase direct and indirect costs. 6,8 Studies have demonstrated that the prevalence of burnout differs between countries and that it may be difficult to generalize research findings from high-income countries to low-and middle-income countries because of cultural differences that may affect factors associated with burnout and its prevalence. 9,10 Additionally, the imbalance between job demands and the resources available underlies the etiology of burnout; 11 this imbalance may differ substantially between low-and middle-income countries and high-income countries. Moreover, the coronavirus disease 2019  pandemic changed the health-care landscape in many countries and introduced additional stressors, such as staff redeployment and the fear of infection. 12 The impact of the pandemic on the prevalence of burnout and the possibility that factors associated with the pandemic may differ across regions warrants investigation.
In 2019, the World Health Organization (WHO) identified good primary health care as fundamental for achieving universal health coverage (UHC), a WHO strategic priority. 13 UHC refers to the provision of universal, cost-effective health services that can be accessed without financial hardship. 13 However, as observed, "health services are only as effective as the persons responsible for delivering them." 14 Thus, the physical and mental well-being of primary health-care professionals is crucial for achieving UHC. There is clear evidence from highincome countries that the prevalence of burnout in health-care professionals differs according to specialty and that the risk may be higher in primary care. 15 Having a good estimate of the prevalence of burnout in primary health-care professionals in low-and middle-income countries is important because this information will provide the first step in identifying ways to mitigate the impact of burnout and to develop culturally and organizationally appropriate interventions.
The aims of this review, therefore, were: (i) to provide a comprehensive overview and meta-analysis of the prevalence of burnout among primary health-care professionals in lowand middle-income countries; (ii) to explore factors associated with burnout in these countries; and (iii) to compare data on burnout collected during the COVID-19 pandemic and the pre-pandemic period.

Methods
When performing this review, we followed the preferred reporting items for systematic reviews and meta-analyses. 16 We conducted an initial systematic search in nine electronic Objective To estimate the prevalence of burnout among primary health-care professionals in low-and middle-income countries and to identify factors associated with burnout. Methods We systematically searched nine databases up to February 2022 to identify studies investigating burnout in primary healthcare professionals in low-and middle-income countries. There were no language limitations and we included observational studies. Two independent reviewers completed screening, study selection, data extraction and quality appraisal. Random-effects meta-analysis was used to estimate overall burnout prevalence as assessed using the Maslach Burnout Inventory subscales of emotional exhaustion, depersonalization and personal accomplishment. We narratively report factors associated with burnout. Findings The search returned 1568 articles. After selection, 60 studies from 20 countries were included in the narrative review and 31 were included in the meta-analysis. Three studies collected data during the coronavirus disease 2019 pandemic but provided limited evidence on the impact of the disease on burnout. The overall single-point prevalence of burnout ranged from 2.5% to 87.9% (43 studies). In the meta-analysis (31 studies), the pooled prevalence of a high level of emotional exhaustion was 28.1% (95% confidence interval, CI: 21.5-33.5), a high level of depersonalization was 16.4% (95% CI: 10.1-22.9) and a high level of reduced personal accomplishment was 31.9% (95% CI: 21.7-39.1). Conclusion The substantial prevalence of burnout among primary health-care professionals in low-and middle-income countries has implications for patient safety, care quality and workforce planning. Further cross-sectional studies are needed to help identify evidencebased solutions, particularly in Africa and South-East Asia.
databases from database inception to 16  Study eligibility criteria are listed in Box 2 (available at: https:// www .who .int/ publications/ journals/ bulletin/ ). We included studies in the meta-analysis if the Maslach Burnout Inventory was used as the measurement tool and prevalence estimates were reported for each of the following three subscales: 19 (i) emotional exhaustion; (ii) depersonalization; and (iii) personal accomplishment. Low-and middle-income countries were defined by the World Bank's 2020 income classification. 18 We exported search results to Rayyan Intelligent Systematic Review (Rayyan Systems Inc., Cambridge, USA) for de-duplication and screening. One reviewer completed title screening and a second reviewer independently screened 10% of titles for comparability. Two reviewers independently completed abstract and full text screening; disagreements were resolved through discussion. We developed the protocol for this systematic review and meta-analysis a priori and registered with PROSPERO (CRD42020221336). 20 Data extracted included: (i) study author ; (ii) year of publication; (iii) country; (iv) region; (v) country income classification; (vi) study design; (vii) study participants; (viii) sampling method; (ix) sample size; (x) participants' mean age; (xi) percentage of female participants; (xii) measurement tool; (xiii) prevalence of overall burnout; and (xiv) prevalence of burnout according to measurement tool subscales and to any associated factors. Two reviewers extracted data independently using a form developed and piloted for the study and at the same time performed a quality assessment using Hoy et al.'s risk-ofbias tool for prevalence studies, 21 details available from the data repository. 17 Disagreements were resolved through discussion. We translated non-English studies using Google Translate (Google LLC, Mountain View, USA).

Data analysis
Study characteristics, the burnout prevalence range and factors associated with burnout are reported narratively for all eligible studies. A random-effects model was used for the meta-analysis. We performed the analysis with MetaXL v. 5.3 (EpiGear International Pty Ltd) using the double arcsine transformation variant for the meta-analysis of prevalence. 22 We calculated pooled prevalence estimates for each score category (i.e. high, moderate and low) in the three Maslach Burnout Inventory subscales and reported with 95% confidence intervals (CIs). Standard values for the subscale score categories are listed in Table 1. Subgroup analyses were carried out for different professional groups. Study heterogeneity was assessed by inspecting forest plots and by calculating I 2 -an I 2 greater than 60% indicated a high degree of heterogeneity. Publication bias was assessed using Doi plots and the LFK index. 23

Results
The literature searches generated a total of 1568 unique articles once duplicates were removed (Fig. 1). After screening, we included 60 studies in the narrative review and 31 studies in the meta-analysis.
used Emotional Burnout Diagnostics. 70 One study included family medicine residents, 68 one nurses, 70 and one community pharmacists. 69 Table 3 summarizes the studies' characteristics.

Burnout prevalence
A single-point prevalence for overall burnout was reported by 43 studies, which used a range of different measurement tools and different definitions of burnout. Estimates ranged from 2.5% for severe burnout among family physicians in China to 87.9% for burnout among midwives in Uganda. 45,65 In the three studies that collected data during the COVID-19 pandemic, the prevalence ranged from 31.5% in community pharmacists to 47.4% in family medicine residents (for severe or very severe burnout) to 50.0% in primary care nurses. [68][69][70] Of 47 studies that reported burnout prevalence determined using the Maslach Burnout Inventory, 31 (involving 14 439 primary health-care professionals) contributed data suitable for the meta-analysis. The risk of bias was assessed as low for 18 of these studies and moderate for 13. No study had a high risk of bias. Of the two studies in the meta-analysis that were published during the pandemic, one collected data before the COVID-19 pandemic and one did not report dates for data collection. Table 4 shows the pooled prevalence of emotional exhaustion, depersonalization and reduced personal accomplishment across the 31 studies. The pooled prevalence was 28.1% for a high level of emotional exhaustion, 27.6% for a moderate level of emotional exhaustion, 16.4% for a high level of depersonalization, 22.7% for a moderate level of depersonalization, 31.9% for a high level of reduced personal accomplishment and 28.1% for a moderate level of reduced personal accomplishment. The combined estimated prevalence of a moderate or high level on each subscale was 55.7% for emotional exhaustion, 39.1% for depersonalization and 60.0% for reduced personal accomplishment. The I 2 for these studies was 98% for the emotional exhaustion subscale and 99% for the depersonalization and personal accomplishment subscales, which indicate a high degree of heterogeneity. Forest plots for high scores on each subscale are available from the data repository. 17 The subgroup analysis showed that high scores for emotional exhaustion were most prevalent in community nurses (pooled prevalence: 33.1%; 95% CI: 22.7-44.0), followed by family physicians (pooled prevalence: 26.1%; 95% CI: 20.3-32.5) and community health workers (CHWs, pooled prevalence: 21.3%; 95% CI: 9.3-34.8). Depersonalization was also most prevalent among community nurses (pooled prevalence for a high score: 30.0%; 95% CI: 11.3-50.7), followed by family physicians (pooled prevalence: 11.5%; 95% CI: 7.8-16.0) and CHWs (pooled prevalence: 10.0%; 95% CI: 6.3-14.5). In contrast, reduced personal accomplishment was most prevalent in CHWs (pooled prevalence for a high score: 33 Fig. 2, Fig. 3 and Fig. 4.

Quality assessment and publication bias
The risk of bias was calculated for each study: 46.7% of studies (28/60) scored between 5 and 7 points, which indicated a moderate risk of bias, and 53.3% (32/60) scored between 8 and 10 points, which indicated a low risk of bias. Studies scored well in domains relating to internal validity but less well in domains related to external validity, such as representative sampling frames and sampling methods.
The Doi plot for a high depersonalization subscale score was symmetrical, with a low LFK index (0.03), which suggests a low risk of publication bias. However, the Doi plots for a high emotional exhaustion subscale score and a high personal accomplishment subscale score demonstrated minor asymmetry, with an LFK index of -1.08 and -1.11, respectively, which suggests a small risk of publication bias. Full details of the risk of bias assessment are available from the data repository. 17

Discussion
Our findings suggest that the prevalence of burnout among primary health-care professionals in low-and middle-income countries is substantial, perhaps unsurprisingly in view of the workforce and resource shortages in these countries. 14,84 However, given that the consequences of burnout include increased sick leave, staff turnover and emigration, there are implications for workforce planning and the recruitment and retention of primary health-care professionals in countries where understaffing is already a critical issue. Any increased desire to emigrate could exacerbate the so-called brain drain from these countries to high-income countries. 8 Policy-makers in low-and middle-income countries may need to work with policy-makers in high-income countries to identify solutions.
We found that the prevalence of emotional exhaustion and depersonalization was highest among primary care nurses, whereas the prevalence of reduced personal accomplishment was highest among CHWs. The high prevalence of burnout among nurses may affect patient safety as they are the main providers of community health care in some low-and middle-income countries. Longitudinal studies are needed to identify causal factors and to determine ways of reducing work demands on primary care nurses. One solution may be to increase the number of family physicians to provide professional support and clinical expertise. However, burnout is also common among family physicians and, therefore, any restructuring of roles and responsibilities must bear this in mind. Although international studies suggest that overall burnout levels among family physicians are similar in low-and middle-income countries and high-income countries, there are differences in the prevalence of each dimension of burnout for different cadres. For example, the prevalence of deperson-alization is lower among primary care nurses in high-income countries than in low-and middle-income countries. 85,86 This result may reflect differences in the responsibilities, workload and type of work expected of primary care nurses in low-and middle-income countries, where they are often responsible for diagnosis, treatment and performing basic procedures. 87 Additionally, in contrast to observations in high-income countries, 24 studies in our review suggest that reduced personal accomplishment is the most prevalent dimension of burnout for family physicians and CHWs in lowand middle-income countries. These results may reflect limited opportunities for further education, professional development and career progression in these countries. Policy-makers need to be aware of these differences, to work actively to identify individuals most at risk of burnout and to develop targeted interventions.
We were unable to compare findings from the three studies conducted during the COVID-19 pandemic with pooled pre-pandemic data because different measurement tools were used. However, the estimated overall prevalence of burnout in two of these studies was higher than the pooled prevalence we found for the individual Maslach Burnout Inventory subscales, 69,70 which is in line with the findings of a global survey of health-care professionals that used a single-item scale to assess burnout during the COVID-19 pandemic and found a prevalence of 51%. 88 Additionally, we found no clear differ-

Systematic reviews
Primary care burnout in low-and middle-income countries Tanya Wright et al.
ence in burnout prevalence between upper-middle-income countries and lower-middle-income and low-income countries. Again, this result was partly due to differences in the definition of burnout and in the measurement tools used, which made comparisons difficult.
In line with previous research, 89 we found conflicting evidence on the association between burnout and sex. This outcome may have been due to: differences in how men and women ex-perience burnout; 89 cultural differences in sex roles; 71 or cultural and sex differences in the importance of protective factors such as social support. 90,91 Our findings suggest that burnout is more common in younger age groups. Younger professionals early in their careers may have greater family responsibilities, which could lead to increased conflict between work and home life and which, combined with lower professional selfefficacy, could result in a higher risk of burnout. 92 In contrast to studies from high-income countries, 93 11 studies in our review found that the prevalence of burnout also increased with the number of years of service; it may be that limited opportunities for career development in low-and middle-income countries lead to frustration and burnout over the years. Our findings imply that burnout prevalence peaks in health workers both at an early career stage and much later in their careers. Consequently, policies and  Primary care burnout in low-and middle-income countries Tanya Wright et al.
interventions to mitigate and prevent burnout should be targeted at these two career stages.
The evidence from our review confirms, as previously established, 93 that burnout is associated with heavy workloads, few workplace resources, insufficient workplace support and conflict at work. One study conducted during the COVID-19 pandemic found that increased exposure to COVID-19 patients and the requirement to supply one's own personal protective equipment were both positively associated with burnout. 68 Another highlighted the need for specific pandemic training and increased organizational resources and support. 69 These results are in line with findings from high-income countries, which highlight the increased workload and stress associated with exposure to COVID-19 patients, the need for extra training and support, and the importance of adequate personal protective equipment. 12,88 Several studies in our review identified factors that protected against burnout, such as regular exercise, regular rest breaks and time away from work, 38,60,73 which could be incorporated into the culture of primary care.
The geographical spread of studies in our review highlights the dearth of research on primary care burnout in low-and middle-income countries, specifically in Africa and South-East Asia, which are the WHO regions with the greatest shortages of health-care professionals. 84 Moreover, most studies were performed in upper-middle-income countries, which limits the generalizability of our results to lower-resource settings. This finding highlights the urgent need for research in low-income and lower-middle-income countries. Importantly, 43% of studies in our review were published from 2019 onwards, possibly reflecting increasing awareness that a healthy primary care workforce is essential for achieving UHC. 13 Study heterogeneity was high due to the breadth of primary healthcare professionals included, the geographical spread of the studies and the variety of burnout measurement tools used. The variety of cultures, economies, disease burdens and political, educational and health systems in study countries would have resulted in differences in workload, resource availability and training, which may have contributed to large variations in the working environment and personal coping strategies between countries. However, the quality of the studies was good as no study was assessed as having a high risk of bias.
We conducted this study using a robust systematic review method and preregistered the study protocol on the PROSPERO website which ensured transparency. However, searches were limited to electronic databases and reference lists. Grey literature was not searched, which means that some data may have been missed, although the  Primary care burnout in low-and middle-income countries Tanya Wright et al.
risk was small. 94 Another limitation was the use of Google Translate rather than translators, which may have introduced errors at the data extraction stage. However, a recent study suggested that Google Translate is adequate for data extraction. 95 One third of the studies retrieved by our searches and fulfilling our inclusion criteria were in languages other than English. Of the 25 studies from the Americas, 19 were not published in English. Excluding these studies would have excluded a considerable amount of regional data.
The findings of this review suggest that over half of primary health-care professionals in low-and middleincome countries have a moderate or high level of emotional exhaustion or reduced personal accomplishment and over a third have a moderate or high level of depersonalization. These results have implications for the health of the primary care workforce, staffing levels and the quality of care. It is necessary to identify protective factors against burnout, such as workplace support, continuing education and regular rest breaks, and to incorporate them into primary care. Further research should be conducted to provide better estimates of the prevalence of burnout and to explore its determinants, especially in underrepresented countries in Africa and South-East Asia, where workforce shortages are greatest. Additionally, this review highlighted the difficulty of making comparisons across regions, countries and professional groups when different measurement tools and definitions of burnout are used. There is, therefore, a need for an international consensus on

Resumen
El desgaste entre los profesionales de la atención primaria de salud en los países de ingresos bajos y medios: revisión sistemática y metanálisis Objetivo Estimar la prevalencia del desgaste profesional entre los profesionales de la atención primaria de salud en los países de ingresos bajos y medios e identificar los factores que se asocian a este síndrome.
Métodos Se realizaron búsquedas sistemáticas en nueve bases de datos hasta febrero de 2022 para identificar estudios que investigaran el desgaste profesional en profesionales de la atención primaria de Primary care burnout in low-and middle-income countries Tanya Wright et al.

Region of the Americas (25 studies)
18 studies from Brazil; six studies from Mexico; and one study from Cuba.

European Region (11 studies) a
Five studies from Turkey; two studies from Bosnia and Herzegovina; two studies from Serbia; one study from Bulgaria; and one study from the Russian Federation.

Western Pacific Region (10 studies)
10 studies from China.

Eastern Mediterranean Region (seven studies)
Four studies from the Islamic Republic of Iran; one study from Egypt; one study from Iraq; and one study from West Bank and Gaza Strip.

African Region (six studies)
Two studies from South Africa; one study from Cameroon; one study from Ethiopia; one study from Uganda; and one study from Zambia.

South-East Asia Region (two studies)
One study from India; and one study from Thailand.
WHO: World Health Organization. a One study included data from Bulgaria and Turkey.